Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sullivan County Health Care during CMS and state inspections, most recent first.
Care plans were not updated for two residents after changes in care needs were identified. One resident had documented sexual activity with another resident and later had an unwitnessed fall linked to improper footwear, but the care plan did not reflect sexual expression needs or new fall interventions. Another resident had hearing loss and bilateral hearing aids, with nursing responsible for insertion, removal, and battery changes, but the comprehensive care plan was not revised to include hearing aid use.
Failure to assist a resident with meals per the care plan. The resident was observed in bed with the meal tray untouched during both lunch and breakfast, with no staff providing feeding assistance. The care plan required one staff assist with all meals and feeding support, but the unit manager, RN, and assigned LNA were not aware of any assistance being provided, and the LNA stated no breakfast assistance had been offered.
An LPN administered insulin to one resident using another resident's previously used insulin pen after the second resident ran out of their own supply. This action, confirmed by staff interviews and medication records, violated both manufacturer instructions and facility policy, which prohibit sharing insulin pens between residents due to the risk of bloodborne pathogen transmission.
A resident who fell and complained of hip pain was moved back to bed by staff before notifying a physician, contrary to facility policy and professional standards. The resident was later diagnosed with a left pubic fracture, highlighting a deficiency in post-fall care protocols.
The facility inaccurately coded MDS assessments for three residents. A resident's dialysis treatment was not recorded, another resident was incorrectly noted as receiving antipsychotic medications, and a third resident's hospice care was omitted. These errors were confirmed by the MDS Coordinator.
Care Plans Not Revised for Sexual Expression, Falls, and Hearing Aid Use
Penalty
Summary
The facility failed to revise care plans for two residents after significant changes in care needs were identified. For Resident #34, nursing notes documented that the resident was found in another male resident’s room with pants off and a brief and bra partially on, and the DPOA stated the resident had been sexually active at the prior facility and did not want staff to stop interactions if both residents were willing participants. Despite this, the care plan did not include any plan for sexual expression, and the DON confirmed the omission. Resident #34 also had an unwitnessed fall in which the resident was found without footwear, and staff identified improper footwear as the root cause. The facility’s fall policy required updating the care plan and adding new interventions to prevent another fall or injury, but no new interventions were added after the fall. For Resident #121, an audiology note stated the resident had hearing loss, used hearing aids, and that nursing staff would insert and remove the hearing aids and change the batteries, but the comprehensive care plan was not revised to include the use of bilateral hearing aids; the unit manager confirmed the lack of updates.
Failure to Assist Resident With Meals per Care Plan
Penalty
Summary
The facility failed to ensure that Resident #31 was assisted with meals in accordance with the resident's care plan. During lunch dining observations on 12/9/25, Resident #31 was observed in bed in the room with eyes closed and the lunch tray untouched in front of the resident, with no staff assisting with the meal. Review of the ADL care plan dated 10/27/25 showed that Resident #31 required moderate assistance by one staff to eat, one staff assist with all meals, and feeding assistance with encouragement to maintain an upright head-of-bed position during meals. During breakfast dining observations on 12/10/25, Resident #31 was again observed in bed with eyes closed and the breakfast tray untouched, and no staff was assisting with the meal. On the unit, 4 of 5 LNAs were observed assisting other residents with breakfast. Staff J, the unit manager, stated the resident had a recent decline in eating and needed staff assistance with meals, but was not aware if anyone was assisting with breakfast. Staff K, the RN, stated no report had been received that the resident declined breakfast and was not aware if anyone was assisting. Staff L, the LNA assigned to the resident, stated the resident needed one staff assist with meals but had not offered breakfast assistance and was not aware if anyone else was assisting.
Insulin Pen Shared Between Residents by LPN
Penalty
Summary
A Licensed Practical Nurse (LPN) administered insulin to one resident using another resident's previously used insulin pen, resulting in potential exposure to bloodborne pathogens. The incident occurred when the LPN used the insulin pen belonging to one resident to administer a dose to a different resident after the latter had run out of their own insulin. This action was confirmed through staff interviews and review of the electronic medication administration records, which showed that both residents had active physician orders for insulin and that the medication was documented as given on the same day. Manufacturer instructions for the insulin pen and facility policy both explicitly state that insulin pens are for single-patient use and must not be shared between residents, even with a new needle, due to the risk of transmitting infections. The Centers for Disease Control and Prevention (CDC) also provides guidance that insulin pens should never be used for more than one patient because blood may be present in the pen after use. The facility's policy further reinforces that medications supplied for one resident are never to be administered to another resident. Despite these clear guidelines, the LPN administered insulin in a manner that violated both manufacturer and facility protocols.
Failure to Follow Post-Fall Protocols
Penalty
Summary
The facility failed to adhere to professional standards of care following a fall incident involving a resident. The resident was found on the floor, lying on their left side, and complained of pain in the left hip. Despite the resident's complaints and the presence of tenderness upon assessment, the resident was moved back to bed with the assistance of three staff members before notifying the provider. This action was contrary to the facility's policy, which mandates immobilization of the resident in the event of suspected fractures or pain, and immediate notification of a physician without moving the injured limb. The facility's policy and the Journal of Nursing's Post Fall Care Nursing Algorithm both emphasize the importance of not moving a resident who may have sustained a serious injury, such as a fracture, and to notify a physician immediately. The resident was later diagnosed with a left pubic fracture at the hospital. The failure to follow these guidelines and protocols resulted in a deficiency, as the staff did not use sound nursing judgment to immobilize the resident and notify the physician before moving them, potentially exacerbating the injury.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS was incorrectly coded to indicate that the resident was not receiving dialysis, despite having an order for dialysis three times a week. Another resident's MDS inaccurately reflected the use of antipsychotic medications, although the resident was not receiving such medications during the assessment period. Additionally, a third resident's MDS did not indicate hospice care, even though the resident had been admitted to hospice. These inaccuracies were confirmed through interviews with the MDS Coordinator.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Unity
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elm Wood Center At Claremont | 5.8 mi | ★★★★★ | 1 | 0 |
| Woodlawn Healthcare Center Llc | 7.4 mi | ★★★★★ | 4 | 0 |
| Cedar Hill Health Care Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Springfield Health & Rehab | 9.9 mi | — | 16 | 4 |
| Gill Odd Fellows Home Of Vermont | 20.4 mi | ★★★★★ | 6 | 0 |
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